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HomeMy WebLinkAbout0084 DONEGAL CIRCLE - Health 84 DONAGEL CIR, CENTERVILLE .x `�lllrl�i UPC 12534 No.2 153LO.R 'lar NAiTIN91,VU Y ' No. �S� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARE� E HEALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIO RMIT Application fir a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ndividual Com onents L a[' Owner's Name p/Parce[04 Address �d n�1► 1 t�./Lot# I_ ' el hone Y�[j '�V�•� n�stal�le's e (fix ' Designer's Name �rlre+s 1 r 1��� �JU Telephone# Telephone# Type of Building: 1� Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(mi .req ired) gpd Calculated design flow gpd Desi n ow pr vid ed gpd Plan: Date Vp C� Number of sheets ' Revision Date Title Description of Soil(s) aA'-'=J I Soil Evaluator Form NO. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersig agrees to ins II the abov escribed Individu S age Disposal System in accordance with the provisions of TITLE 5 and forth grees not top the sys m operation ntil a cate of Compliance has bee issu d by the Board of Health. Signed Date -7 Z� Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 g � No. 7 THE`CON",OAWEA TH OF MASSACHUSETTS FEE BOARDg,;,,--P,,,HEALTH 1D OF APPLICATION,,.FOR DISPOSAL SYSTEM CONSTRUCTIO>XERMIT Applicatioi P'r a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ndividual Com onents L cat ( Owner's Name p/Parcel Address �� /'1 D) )]j/�/Lo[# �t�W5 el hone �'1� F�� (�J L"/f� 7D �q �) r /�- nstalle 's N �et Designer's Name A��iA_1 Z17 71 TeOp one# G/• l��+V1 Telephone# as Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(mi .req fired) gpd Calculated design flow gpd Design ow pr vided gpd Plan: Date I0 ;-7-01Number of sheets �_ Revision Date 4-1 Title Description of Soil(s) " Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersig agrees to install?he abov escribed Individu S age Disposal System in accordancwwith the proyisions of TITLE 5 and fur �topsXs m' operation ntil a ficat th gree e of Compliance has been issu'd by the Boakd=of'H alth Signed Date , Inspections >> 5 FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 s+. -----r---o.ate ® ---------w--------uCryW--------e--r- --w---.�+ur r�srr aur.rvm.ssr wrr.�. No. r 5 —O q tv THE COMMONWEALTH OF MASSACHUSETTS FEE �Q ��- BOARD OF HEALTH C ATIFICATE OF COMPLIANCE .Description of Work: VIndividual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed ),Repaired(traded( ),Abandoned( ) ID at ' C)y� r has been installed in accordance with the provisions of 31q CNIIlIZ 15.00 (Title 5) and the approved design plans/as-built plans relating to ltcation No f S-c q& dated bo t\ A roved Design Flow d P g PP � .,�- ,DPP\ g —(gpd) Installer �� Z�i ^', w ^ Designer: ' Y�AA�""�i' Inspector ate The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No / �3--a'-)4- THE CO.M-MON EALTH OF MASSACHUSETTS FEE /0 0 BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby rant o Construct ( ) Repair ( P-rotpgrade ( ) Abandon ( ) an individual sewage disposal system 14 as described in the a licafio for D> o`sal S s em Corns ruction Pe.mi No, Q 1S dated h Provided Const'rufc0 g3shafl b�compleCed w tlitn Chre�years,c t11e da this r 't l co ditions must be met. Date 4 I �� Board of Health R FORM 2 - DSCP DEP A17ROVED FORM 5/96 FORM 1255 (REV 5/96) H&•W,F�HOB PSB<I1#/�IA{H_T,"r"' PUBLISHERS- BOSTON R E C L Pr i rit0d: June 9. 2015 @ 8:23:56 BARNSTAELE COUNTY REGISTRY OF DEEDS JOHN F. MEADE, REGISTER Tr ans#.�— 3 Oper:KATHLEEN " 'DAVID-- Book.: 2�92; rage: 92 Inst#: 26246 Ctl#: 87 4c:6-09-2015 Cal 8:22:59a BARN 8"� C)ONEG4r'l UP DOC DESCRIPTION TRANS AMT 1 CHAMBERLIN, JUDITH --- -- RESTRICTION County Fee $ 10.00 10.00 Surcharge CPA $20.00 20.00 State Fee 140.00 40.00 Surcharge Tech $G5.00 5.00 Tctal fees: 75.00 x*� Total charges: 75.00 . j ('HECK RPt 202 75.00 DEED RESTRICTION The Barnstable Board of Health requires that the following notification be placed on the property deed; The Massachusetts Department of Environmental Protection and as interpreted by the Barnstable Board of Health require that the owner be aware that the leaching facility installed is designed to accommodate three (3) bedrooms but the dwelling shall remain as two (2) bedrooms due to the property being located in a nitrogen sensitive area. at the property at: 84 Donegal Circle, Centerville, Massachusetts, Map 169, Parcel 75, as currently owned by Judith Chamberlin, as property referenced in the Barnstable Registry of Deeds as Book# 15406 Page# 197. I, J �►`�'� (� irvl �► and as the owners/executors of the property/trustee referenced above acknowledge the deed restriction(s) being placed on the property. ers/Executor Signature at The person named above: _J t+L"' (y , acknowledges the foregoing instrument to be his/her free act and deed, before me. Notary Public My ills F^ •'�lom LY AEY O Lm umb t Aerch 12,M21 BARNSTABLE REGISTRY OF DEEDS John F. Meade, Register 1 r1 f I p 1 ------------ _ S I 0,1 ID : 'down of Barnstable .,ofIHErpky Regulatory Services Richard V. Scali, Interim Director + 9ARNsrABEZ, 9 MASS. g Public Health Division �p t639• �m Thomas McKean, Director 200 Main Street, Hyannis, iVIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form 1l. f.! / Date: i Sewage Permit#Zd -04/6 Assessor's IVlap\Parcell.�7� 5 Designer: i ti�� Installer: C"'WiW1"-A4— CW` ,, Address: Address: On 6111 13� Coant"ok, M& , vas issued a permit to install a (date) (installer.) septic system at 70� OW—LF-- based on a design drawn by,,. .,, (address) MOO LJ dated 3 1 D 2,01 S VZ (designer) 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I.certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component oIthe septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were"found satisfactory. I certify that the system referenced above was constructed om lance with the terms o the I\A approval letters.(if applicable) �;i 0`�/,I`c .4 DAVID st Signature) UTASON Ni).106e r. •:" 1 � w (Designer's Signature) (Affix Desij -� p Here) PLEASE RETURN TO BARINSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CONIPLIANNCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Forth Rev8-14-13.doc � 2 _ Z1.2-��j� k fBab ab e P �j s -0 O opHE 'L Department of Regulatory Services 1 B AB;,e. Public Health Division Date I .e79. 200 Main Street,Hyannis MA 02601 Y iOjEo hta+ � Date Scheduled ime Fee Pd.---�_f I Soil Suitability�sment for'Se�&" al Performed By�� Witnessed By: 1�LOCATION&GENERAL INFORMATION !-- Location Addres � `/ ^ Owner's Name f, NV/44, /v 1 Address T f� Assessor's Map/Parcel: /�J 9/ Engineer's Name �J. NEW CONSTRUCTION REPAIR / Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft ing ter Well ft q Drainage Way ft Property Line ft Other ft FEB 23 t$# �.Si E (;, (Street name,dimensions of lot,e. ations of test holes&perc tests,locate wetlands in pro.'n to holes V Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date Time Observation Hole# Time at 9" Depth of Perc Time at 6" SW Pre-soak Time @ � Time(9"-6") End Pre-soak 101::�',. Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC , . DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) ,(Munsell) Mottling (Structure,Stones,Boulders. n Consistency-%Gravel Ks3 r�G(J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. -- Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis[encv%Gravel) Flood Insurance Rate Man: Above 500 year flood boundary No Yes_ Within 500 year boundary No Y Yes_ Within 100 year flood boundary No�Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi us erial exist in all areas observed throughout the area proposed for the soil absorption system? Lit �, )�,Q/� If not,what is the depth of na lly occurring pery ous material? WA Certification //}} I certify that on 1® —1 (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the re uired training,expertise and expe escribe 310 CMR 15.017. Signature Date 10 Q:\SEPTlC\PERCFORLM.DOC TOWN OF BARNSTABLE LOCATIONA�G/I *_ SEWAGE# %OY6. VILLAG ASSESSOR'S MAP&PARCEL 169 7 INSTALLER'S NAME&PHONE NO�1Q,e®i,�e rajS-1 — C/ SEPTIC TANK CAPACITY 1OL-0 0,0//Gru �''> LEACHING FACILITY: (type �'� //�n(�F44&6ize) Z 4 3 NO.OF BEDROOMS' 2 OWNER PERMIT DATE: !/ / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �y O oAe Cnl Ci rc� �6 o Commonwealth of Massachusetts AUK Executive Office of Environmental Affairs0 3 I9g9 De arrtment of F� Environmental Protection A 4 William F.Weld ti Governor Trudy t:oxe Secrotsry,EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATIO(V // -n v` Property Address: �`7, 6c/0 f I �r Address of Owner: cL �1�./®1 J 5 ✓ Date of Inspection: v q— 9' (If different) Name of Inspector: 111 J�`"� Z j4"6V 5 �� Company Name, Ad ress an a ephone Number: CERTIFICATION STATEMENT © $fp [iff 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se ge disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Q Inspector's Signature: Date: lin �'0-0 f4 The System Inspector shall submit a copy o is inspect t the Approving Authority wihirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to :ne system owner ana copies sent to the buyer, if applicable and the approving authora . INSPECTION SUMMARY: 1 Check A, B; C, or D: S: Ttt found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not,determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with'a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)SS6-1049 a Telephone(617)292-SM iI Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Lf BJ SYSTEM CONDITIONALLY PASS ontinued) _ Sewage backup or breakout at high static water le el observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The systern has a septic tank and soii absorption system and is within 100 feel lu a surface water supply or tobutai y iu a surface water supply. _ The systen, has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 'DJ SYSTEM FAILS (continued): fistribution Static liquid level in the box above outlet' vert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is lesss than 1/2 day Flow. Required pumping more than 4 times in the last year NOT due to clo ed or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorpti n System, cesspool or privy ' below the high groundwater elevation. Any portion of a cesspool or privy i within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is i hin a Zoe I of a public well. Any portion of a cesspool or privy is withi 50 feet of a private water supply well. Any portion of a cesspool or privy is ess than 0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (the well has n analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile orga ic compounds, amm nia nitrogen and nitrate nitrogen. ]LARGE SYSTEM FAILS: The following criteria apply/mIlarge systems in addition to the criteria ab ve: The design flow of sys)em is 10,000 gpd or greater (Large System) and the sy m is a significant threat to public health and safety and the environment/because one or more of the following conditions exist: the Sys t�is within 400 feet of a surface drinking water supply — the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) he owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program uirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department For further information. (revised 8/1S/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 004 f f Property Address: 0 1 S Owner: 0 u FfZ Date of Inspection: ,T Check if the follo � y,Kjg`hav e been done: _ Pumpi g information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examine d. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. �� hesystem-cloes not receive non-sanitary or industrial waste flow he sit as inspected for signs of breakout. II system omponents, the Soil Absorption System, have been located on the site. e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, mat i of construction, dimensions, depth of liquid, depth of sludge, depth of scum. e size an cation of the Soil Absorption System on the site has been determined based on existing information or appro ated by non-intrusive methods. he facilii) o,%nc: ;and occupants, if different fron^ o„•ne-? were provided witk information on the proper maintenance of Sub- Surface Disposal System. vised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: G� �� �6�� CPA Ile Owned /�U%(,� Fr? er rSly` Date of Inspections FLOW CONDITIONS RESIDENTIAL: Design flow: al s Number of bedrooms: 'Number of current residents:_ arbage grinder (yes or no): ® sundry connected to syste ( or not: easonal use (yes or no): D � �� po O 9 ater meter readings, if available: ast date of occupancy: OMMERCIAUI NDUSTRIAL: ype of establishment: esign flow: gallons/day rease trap present: (yes or no)_ dustrial Waste Holding Tank present: (yes or no)_ on-sanitary waste discharged to the Title 5 system: (yes or no)_ eater meter readings, if available: ast date of occupancy: THER: (Describe) ast date of occupancy: GENERAL INFORMATION 'LIMPING RECORDS and source of information: System pumped as part of inspection: (ye o)_ If yes, volume pumped. gal n. Reason for pumping: PE F STEM Septic 11 absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) OPPROXIMATE AGE of all components, date installed (if known) and source of information: ----� — c2 'sewage odors detected when arriving at the site: (yes or no)&(, (revised 8/15/951 $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( O1,07 e7 fI 0/�r Owner: ' v Date of Inspection: U7 L SEPTIC TANK:_ dw iro rrn cite 0;iro ll Depth below grader Material of construction: Crete _metal _FRP _other(explain) Dimensions: Sludge depth: Distance from top f ludge to bottom of outlet tee or baffle Scum thickness:� Distance from top of scum to top of outlet tee or baffler"' Distance from bottom of scum to bottom of outlet tee or bale: Comments: (recommendation for pumping, condition o�f} let and outlet tees or ba I s, depth of liquid level in relation to utlet 'nve structural integrity, evidence of leakage, etc.) YG oy„ Q�� GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP _oth explain) Dimensions: Scum ihickness. Distance from top of scum to top of outlet t or baffle: Distance from bottom or .rum .t ` bottom t out t tee or bathe Comments: (recommendation for pumpin , condition of inlet and tlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of lea ge, etc.) i . (revised 8/!5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete ®met\—FRPther(explain) i Dimensions: Capacity: gallons Design flow: gallons/dad• Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches\etc.) ISTRIBUTION BOX:_ locate on site plan) epth of liquid level above outlet invert: omments: note if level and distribctir:^ i, eq_:2' e�.�de_ce of so!ws car ove,, evidence of leakaee 'nto or out of box etc) UMP CHAMBER:_ locate on site plan) umps in working order.(yes or no) omments: note condition of pump chamber, conditi n of pumps and appurtenances, etc.) Al (revised 8/15/95) 7 1 'l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -onntinued) Property Address: ��h 10/ C;r— Owner: o A v.id Date of Inspection: g SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number.y leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert. Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwate,. inflow (cesspool must be pumped as part N�in5pe;n)___�_ Comments: (note condition of soil, signs ofXhyaulic failureXleof ponding, condition of vegetation;etc.) PRIVY:_ (locate on site plan) Materials of constru n: Dimensions: Depth of solids: Comments: (no condition of soil, signs of hydraulic failure, level of ponding, condition �ntion, etc.) (revised 8/15/95) 8 IDate SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f�%J Owner: {�of Inspection: d� Q �� Acj�- '9� � 4� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 0641a 3� (door r r� r ' a la ` DEPTH TO GROUNDWATER / &O v 14 Lv A Ok Depth to groundwater:4 `feet method of determination or approximation: OP y✓//��0'1 5 (revised B/15/951 9 ASSESSORS MAP: TEST HOLE LOGS PARCEL: t wn � 7 _.---_ _ � I) The installation shall com�l with Title V au�) Town of I oard oX. - _ SOIL EVALUATOR: � M� eahli Regulations. i FLOOD ZONE. b 1 �����? � I I � j s . WITNESS : t A Mlo"A�_19 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: : 2j -;-� ? (� � � Z DATE: O' components prior to installation and setting base elevations. t1e: r /L PERCOLATION RATE: .G 1 3) All gravity septic piping to be 4 inch Sch 40 ['VC at I/8"per foot. The first 22 b Y p PP g 4 v. 4Z.0 Vil/ _ _ jti/� Z�O� two feet out of the d-box to the leaching shall be level. x TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other - u purpose other than the proposed system installation.AO i '�,� � � ��tmv 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over[I 10 septic components. i 7) The property is bounded by property corners and property (ines. 8) The property owner shalt review design considerations to approve of total LOCATION MAP 4fi �J� design flow and number of bedrooms to be considered for design. Receipt Gn of payment for the plan and installation based on the plan shall be deemed �"�. on approval of the design flow by the owner. C l C �'� 9) The existing leaching or cesspools shalt be pumped and filled with material i per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per Title V specs. j \\� J 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted it applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. SEPT I C SYSTEM STEM DES I G N 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. --� FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas Line if such Zs .� � exists. � / � \ �/' BEDROOMS AT �� GAL/DAY/DEDROOtvI - '� I O GAL/DAY 13)The installer shalt verify the location, quantity and elevation of the sewer lines exiting the dwelling'prior to the installation. SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. I I" =GAL/DAY x 2 DAYS �1.L.�GAL �-- IJD USE GALLON SEPTIC TANK -E-""-_ It ( ? SOIL AR Pz.1'ION -SYSTET SIDE AREA: ZX ,._ �( I _ N DOT"I"off AREA:___ l ' >( z ' X, p ,-T� Z 0 MAsor1„ U7 r 40� o m I I v 0.41)6 Ul wy SEPTIC . SYSTEM SECTION i o C �'1"7 w — -� ' o Q i j,i ! 7 5`1bt►1 0 �- GU0 GAL Q SEPTIC TANK I i � 7/ r! won t7r Ao'i" gout fowl' .D7 ' , 4 S 1.TE AND SEWAGE PLAN i I LOCATION : e-A 7TbHEtrPCL, SI G MIA PREPARED FOR : ��w ,Ch -CO ATI M I L)r, SCALE: ) I :; W DAV I D B . MASON RS DATE: 10 0l DBC ENVIRONMENtiAL DESIGNS BATE HEALTH AGENT EAST SANDWICH . MA Z ( 508 ) 833- 2177 . ► I ASSESSORS MAP: i (-oGU1 _ TEST HOLE LOGS i PARCEL: 75 ' l) The installation shall comt>l tivtth Title V and Town of�ivjlNicnoarda — -� EVALUATOR: W SOIL '�=-- FLOOD ZONE: I feaUh Regulations. w WITNESS : �VJA MIQ 2) The installer shall verify the location of utilities sewer inverts and septic REFERENCE: DATE: p► k (Zt'j j� }� Z O components prior to installation and setting base elevations. PERCOLAT ION RATE* 1 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first w two feet out of the d-box to the leaching shall be level. TH- TN-2 proposed Y 4) This plan is not to be utilized for property line determination nor any other 1 purpose other than the ro osed system installation. rjq .1 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over If 10 septic components. W' 7) The property is bounded by property corners and property lines. i p p Y It 11040it 2 8) The property owner shalt review design considerations to approve of total i LOCAT I ON MAP design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed { i n approval of the design flow by the owner. i 9) The existing leaching or cesspools shall be pumped and filled with material ! I if per Title V abandonment procedures. Those within the proposed SAS shall �i be removed along with contaminated soil and replaced with clean sand per ,► b �,O Title V secs.�� � p � 10)System components to be 10 feet from water line. Sewer lines crossing the 41� water line shalt be sleeved with 4 inch SCII 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service S line. The line is to be sleeved as aforementioned and maintained in place. SEPTIC ..SYSTEM DES I GN - 11) If garbage grinder exists it is to be removed and is the responsibility of the .-� owner to ensure such. FLOW ESTIVATE 12)The installer is to take caution in excavation around the gas line if such j exists. � � � Z� I \ BEDROOMS AT ((O GAL/DAY/BEDROOM - "� I0 GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling'prior to the installation. I SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. I I I =GAL/DAY x 2 DAYS - IMQ GAL USE I GALLON SEPTIC TANK I LA4 SOIL A896111 P11 ESN—SYSTEM I / OF A t4N d G SIDE AREA. Z ,7 �, o DAVIDy LS 8. G N BOTTOM AREA: I ' >( Z X Q 7< Z�OC a MASON _M 0 PIP U1 SEPTIC , SYSTEM SECTION _ � C�X� 61 �4q d� o TOM— D ID 1G0t7 AL r�i o SEPT I C TANK 7/ ' A_:_V ?,V311-1� _I----1�!M� �I(�-- S I.T E AND SEWAGE PLAN 5 LOCATION : __ 7PPHF Na'Lg, V1 A PREPARED FOR : oy1auw�u cw5oy, a , i P T ! SCALE: W DAV I D B . MASON R5 DATE: 10 0l 5 DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA ! Z ( 508 ) 833- 2177